Key result
Elevated baseline BNP independently predicts MACE in conservatively managed asymptomatic severe aortic stenosis.
Why the study?
Risk stratification is particularly important for asymptomatic patients with severe AS and normal LVEF who undergo conservative management, motivating an exploration of which parameters best predict worse outcomes in this group.
Does brain natriuretic peptide (BNP) predict major adverse cardiovascular events in asymptomatic patients with severe aortic stenosis and normal left ventricular ejection fraction managed conservatively?
RCT (n=157)
Randomized
Does brain natriuretic peptide (BNP) predict major adverse cardiovascular events in asymptomatic patients with severe aortic stenosis and normal left ventricular ejection fraction managed conservatively?
In asymptomatic patients with severe aortic stenosis and normal LVEF managed conservatively, a BNP level ≥94 pg/ml is the best independent predictor of major adverse cardiovascular events and may help identify high-risk patients who would benefit from early aortic valve replacement.
Answers are grounded in this paper and cite their sources.
BNP ≥94 pg/ml was associated with MACE in conservatively managed asymptomatic severe AS; hypothesis-generating for early AVR trials.
Introduction Randomized trials demonstrated that prognosis of asymptomatic patients with severe aortic stenosis (AS) is worse with conservative management compared to early intervention. Among those who are put on conservative management risk stratification is particularly important. Thus, we used data from the AVATAR trial to explore which parameter best predicts worse outcome in asymptomatic patients with severe AS and a normal left ventricular ejection fraction within the group of patients randomized to conservative management. Method AVATAR trial randomized total of 157 patients (79 to conservative management) with asymptomatic severe AS and normal LV systolic function to early surgical AVR or conservative management. The primary outcome was major adverse cardiovascular events (MACE: the composite of death, acute myocardial infarction, stroke, or unplanned HF hospitalization). Cox proportional hazards models were used to assess predictors of MACE. Statistical significance was defined as p ˂ 0.05. Results The average age was 67 years, 57% were men, and the median Society for Thoracic Surgeons predicted risk of mortality score was 1.7%. Overall median follow-up in survivors was 68 months (IQR 58–79). During the follow up, 36/79 (44%) patients in conservative group underwent aortic valve replacement (AVR) due to AS-related indications. There was a total of 55 MACEs, 37/79 (46.8%) of them in the conservative treatment group. According to the univariate cox regression analysis brain natriuretic peptide (BNP) was found to be the only independent MACE predictor in patients randomized to conservative management.; Figure 1 The BNP value of 94 pg/ml was identified as the best (cut-off) predictive value for the occurrence of MACE, with a sensitivity 77.8% and a specificity 72.0% (AUC 0.784, p=0.001; Figure 2). Conclusion BNP is the best independent outcome predictor in asymptomatic patients with severe AS and a normal LVEF. Risk stratification with this parameter may help in optimal selection of asymptomatic patients considered to be at higher risk and who would additionally benefit from early AVRFigure 2Figure 1
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Banovic et al. (2026) conducted an RCT in Asymptomatic severe aortic stenosis with normal left ventricular systolic function (n=157). Brain natriuretic peptide (BNP) risk stratification in conservative management vs. Early surgical aortic valve replacement (AVR) was evaluated on Major adverse cardiovascular events (MACE: composite of death, acute myocardial infarction, stroke, or unplanned heart failure hospitalization) (AUC 0.784, p=0.001). Brain natriuretic peptide (cut-off 94 pg/ml) independently predicted MACE in conservatively managed asymptomatic severe aortic stenosis (AUC 0.784, p=0.001; MACE rate 46.8%).
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